Q: Our doctor ordered a diagnostic colonoscopy because the patient was 'due for 5-year repeat given adenoma of 6mm on last procedure in 2011.' The patient is being screened for colon cancer, but at an interval of five years instead of 10 because of the polyp. The patient's insurance covers screening colonoscopy. The patient would like the doctor to change the referral from diagnostic colonoscopy to screening. Thoughts?
A: What this comes down to is the patient wanting insurance to cover the procedure.
With a Z98.89, h/o colonoscopy with polypectomy submitted with the procedure and maybe even the pre-authorization, it becomes diagnostic. The larger view is that the 'screening' scope is a scope in the absence of a reason to suspect a problem — you have a reason to suspect a problem. So if you change it you are gaming the insurance to get them to pay (fraud/racketeering).
Q: We've been getting [recovery audit contractors] related to global billing. We are told that physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician; so if you see your partner's patient post-operatively, you cannot bill for that visit.
My lead physician says, "If I consult on a patient with for instance, pseudotumor cerebri, and send them to have surgery to protect vision in the right eye, I must still follow them for their vision in the other eye. This must not be absorbed into the global, as I am following them for the original condition, but not just in the surgerized eye. I assume this one can be appealed if they ask for their money back?
The same is true if I diagnose a pituitary tumor. When I see them after surgery, I am seeing them to attend to a whole different organ system (the eyes/vision) than the pituitary gland. I'm not in the global am I?
A: The 'what you are told' part is verbatim CMS guidance and is correct per their guidelines. These appear to be somewhat hypothetical questions, but there are some nuances within them that can change the answer.
As regards the first case, the pseudotumor cerebri, where the patient is sent to 'have surgery' to protect the right eye — who was the surgeon doing the surgery? If that surgeon is in the same group and of the exact same specialty (neuro-ophthalmology), any follow up that Dr. A does on that surgerized eye is included in the global. This is the only permutation of these circumstances where the global period applies to Dr. A.
We need to know the exact specialty of that surgeon. As to case one, the surgical period does not apply if:
- The other surgeon is not a neuro-ophthalmologist
- Dr. A is following up on the other eye